A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?
Obtain filterless IV tubing.
Place the blood in a warmer for 1 hr.
Use a 24-gauge IV catheter.
Prime IV tubing with 0.9% sodium chloride.
The Correct Answer is D
Rationale:
A. Obtain filterless IV tubing: Blood transfusions require specialized IV tubing with an in-line filter to remove clots and debris. Using filterless tubing would increase the risk of transfusing particulate matter into the client’s bloodstream.
B. Place the blood in a warmer for 1 hr: Blood should only be warmed if specifically prescribed and done using an approved device immediately before administration. Prolonged warming increases the risk of bacterial growth and hemolysis.
C. Use a 24-gauge IV catheter: Packed RBCs should be administered through a larger-bore catheter (typically 18–20 gauge) to allow adequate flow and prevent hemolysis. A 24-gauge catheter is too small for efficient transfusion.
D. Prime IV tubing with 0.9% sodium chloride: Normal saline is the only compatible solution for priming and administering blood products. It prevents clotting and hemolysis while ensuring that the blood flows freely without interacting with other IV solutions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. The client brushes her teeth twice daily: Brushing teeth at least twice a day is recommended to reduce plaque buildup, prevent tooth decay, and maintain oral health. This practice is consistent with standard personal hygiene guidelines.
B. The client wipes back to front when toileting: Wiping from back to front increases the risk of transferring bacteria from the anal area to the urethra, which can lead to urinary tract infections. The correct method is front to back.
C. The client washes her perineum first when bathing: The perineal area should be washed last to avoid transferring bacteria from this region to other parts of the body, especially the face. Washing it first increases the risk of cross-contamination.
D. The client takes a hot bubble bath every day: Daily hot bubble baths can dry out the skin and disrupt normal skin flora, potentially leading to irritation or infection. Mild, less frequent bathing with warm (not hot) water is healthier for skin integrity.
Correct Answer is B
Explanation
A. Splitting behavior: Splitting, or viewing people as all good or all bad, is characteristic of borderline personality disorder rather than histrionic personality disorder. It reflects difficulty integrating positive and negative aspects of self and others.
B. Emotional lability: Clients with histrionic personality disorder often display rapidly shifting emotions, exaggerated expression of feelings, and attention-seeking behaviors. Emotional lability is a hallmark feature, making this an expected manifestation.
C. Self-centered behavior: While clients with histrionic personality disorder may seek attention, overt self-centeredness and grandiosity are more characteristic of narcissistic personality disorder rather than histrionic traits.
D. Suspicious of others: Suspiciousness and distrust are typical of paranoid personality disorder. Clients with histrionic personality disorder are generally sociable and seek approval rather than displaying pervasive mistrust.
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